Management of

Upper Limbs
Fractures
dr. Vicky William, Sp.OT

PABOI CABANG SULAWESI TENGGARA

 Upper Limbs Scope
1. Clavicle Fractures – Midshaft
2. Humeral Shaft Fractures
3. Radius and Ulnar Shaft Fractures
4. Metacarpal Fractures
5. Phalanx Fractures

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1. Clavicle Fractures – Midshaft
 Pathophysiology
MECHANISM OF INJURY

• fall onto lateral aspect of

shoulder (85%)
• direct impact to clavicle 

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 Pathophysiology
DISPLACED FRACTURES
• medial fragment
pulled posterosuperiorly by
sternocleidomastoid muscle 
• lateral fragment
pulled inferomedially by
pectoralis major and and weight
of arm 

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 Presentation
History
• popping or cracking sound near shoulder after fall

Symptoms
• acute onset of anterior shoulder pain or directly over clavicle

Physical exam
• inspection
• tender, swelling, crepitus and deformity over clavicle
• skin tenting (impending open fracture) 
• neurovascular exam
• assess subclavian vessels and brachial plexus 
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 Presentation

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 Radiographs
Upright AP clavicle
• supine may underappeciate displacement with gravity
eliminated

15° cephalic tilt (zanca view) 

• eliminates overlapping scapula 

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 Treatment
NONOPERATIVE

Indications
• < 2cm shortening and displacement
• < 1cm displacement of the superior shoulder suspensory complex 
• closed and no neurovascular injury
• low demand patient 
Modalities 
• sling
• figure-of-8 strap
• elevate and extend shoulder to bring distal fragment to the proximal fragment
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 OPERATIVE TREATMENT INDICATION
Absolute Relative and controversial
• open fractures • displaced with > 2cm shortening  
• displaced fracture with skin • bilateral displaced clavicle
tenting  fractures
• Neurovascular injury • brachial plexus injury
• floating shoulder (clavicle and • closed head injury
scapular neck fracture) • seizure disorder
• polytrauma patient

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 Summary
• Midshaft Clavicle fractures are common traumatic injuries
caused by a direct impact to the shoulder girdle and is most
commonly seen in young, active adults.
• Diagnosis can be made radiographically with AP and cephalic
tilt clavicle x-rays. 
• Treatment is nonoperative or operative based on patient activity
and demands, along with degree of displacement, shortening,
and comminution. 

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2. Humeral Shaft Fractures
 PRESENTATION

Symptoms
• pain
• extremity weakness

Physical exam
• examine overall limb alignment
• will often present with shortening and in varus
• preoperative or pre-reduction neurovascular exam is critical
• examine and document status of radial nerve pre and post-reduction

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 IMAGING

AP and lateral
• be sure to include joint above and below the site of injury 

transthoracic lateral
• may give better appreciation of sagittal plane deformity 
• rotating the patient prevents rotation of the distal fragment avoiding further
nerve or soft tissue injury

traction views
• may be necessary for fractures with significant shortening, proximal or distal
extension but not routinely indicated

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 IMAGING

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 TREATMENT
NONOPERATIVE

COAPTATION SPLINT FOLLOWED BY FUNCTIONAL BRACE  

Indications
• indicated in vast majority of humeral shaft fractures
• criteria for acceptable alignment include:  
• < 20° anterior angulation
• < 30° varus/valgus angulation
• < 3 cm shortening

Absolute Contraindications
• severe soft tissue injury or bone loss
• vascular injury requiring repair
• brachial plexus injury
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 OPERATIVE TREATMENT INDICATION
Absolute Indications Relative Indications
• open fracture • bilateral humerus fracture
• vascular injury requiring repair • polytrauma or associated lower extremity
• brachial plexus injury  fracture  

• ipsilateral forearm fracture (floating • pathologic fractures

elbow)   • burns or soft tissue injury that precludes
• compartment syndrome bracing

• periprosthetic humeral shaft fractures • fracture characteristics:

• distraction at fracture site  
at the tip of the stem
• short oblique or transverse fracture pattern
• intraarticular extension
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 Summary
• Humeral shaft fractures are common fractures of the diaphysis
of the humerus, which may be associated with radial nerve
injury.
• Diagnosis is made with orthogonal radiographs of the humerus.
• Treatment can be nonoperative or operative depending on
location of fracture, fracture morphology, and association with
other ipsilateral injuries. 

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3. Radius and Ulnar Shaft Fractures
 Pathophysiology
MECHANISM OF INJURY
• direct trauma
• direct blow to forearm
• indirect trauma
• motor vehicle accidents
• falls from height
• axial load applied to the forearm through the hand

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 Associated conditions
Elbow And DRUJ Injuries
• Galeazzi fractures 
• Monteggia fractures 
• Essex-Lopresti injuries

Compartment Syndrome
evaluate compartment pressures if concern for compartment
syndrome

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 PRESENTATION
Symptoms Neurovascular exam
• pain and swelling • assess radial and ulnar pulses
• loss of forearm and hand function • document median, radial, and
• Physical exam ulnar nerve function

Inspection Provocative Tests

• gross deformity • pain with passive stretch of
• open injuries fingers
• check for tense forearm • alert to impending or present
compartments compartment syndrome
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 IMAGING

Radiographs
Recommended Views
• AP and lateral views of the forearm 

Additional Views
• ipsilateral AP and lateral of the wrist and elbow
• to evaluate for associated fractures or dislocation
• radial head must be aligned with the capitulum on all views

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 TREATMENT
NONOPERATIVE
Cast Or Brace Immobilization
Indications
• completely nondisplaced fractures in patients who are
not surgical candidates
Modality
• Bracing  functional fracture brace
• Casting  Muenster cast with good interosseous mold 
Outcomes
• high rates of non-union associated with non-operative
management

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 OPERATIVE TREATMENT
INDICATIONS
• Severe soft tissue injury (gustilo IIIB)
• Nearly all both bone fractures in surgical candidates  
• Gustilo I, II, and IIIA open fractures
• Open fractures with significant bone loss
• Bone loss that is segmental or associated with open
• Nonunions of the forearm
• Very poor soft-tissue integrity

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 Monteggia Fractures
A Monteggia fracture is defined as a proximal 1/3 ulna fracture
with an associated radial head dislocation.

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 Galeazzi Fractures
A galeazzi fracture is a distal 1/3 radial shaft fracture with
an associated distal radioulnar joint (DRUJ) injury.

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 Summary
• Radius and ulnar shaft fractures, also known as adult both bone
forearm fractures, are common fractures of the forearm caused
by either direct trauma or indirect trauma (fall).
• Diagnosis is made by physical exam and plain orthogonal
radiographs.
• Treatment is generally surgical open reduction and internal
fixation with compression plating of both the ulna and radius
fractures.

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4. Metacarpal Fractures
 ETIOLOGY
Mechanism of Injury
• direct blow to hand or rotational injury with axial load
• high energy injuries (ie. automobile) may result in multiple fractures
Associated Conditions
• wounds may indicate open fractures or concomitant soft tissue injury
• tendon laceration
• neurovascular injury

• compartment syndrome
• closed injuries with multiple fractures or dislocations
• crush injuries
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 PRESENTATION
Physical exam
• inspect for open wounds and
associated injuries
• deformity indicates location
• motor examination
• neurovascular examination

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 IMAGING
RADIOGRAPHS
Recommended views
• PA
• Lateral
• ER oblique
• best view to see 4th/5th CMC
fracture/dislocation
• IR oblique
• best view to see 2nd/3rd CMC
fracture/dislocation

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 TREATMENT
NONOPERATIVE 

Indications
• must be stable pattern
• no rotational deformity
• acceptable angulation & shortening (see table)

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 Acceptable Nonoperative Criteria 
Acceptable shaft Acceptable shaft Acceptable neck
angulation (degrees) shortening (mm) angulation (degrees)

Index & Long finger 10-20 2-5 10-15

Ring finger 30 2-5 30-40

Little finger 40 2-5 50-60

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 OPERATIVE TREATMENT
INDICATIONS
• Open fractures
• Intra-articular fractures
• Rotational malalignment of digit
• Significantly displaced or angulated fractures
• Multiple metacarpal shaft fractures  

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 Summary
• Metacarpal Fractures are the most common hand injury and are
divided into fractures of the head, neck, or shaft.
• Diagnosis is made by orthogonal radiographs the hand.
• Treatment is based on which metacarpal is involved, location of
the fracture, and the rotation/angulation of the injury.

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5. Phalanx Fractures
 Pathophysiology
MECHANISM OF INJURY
Depends on age
• 10-29 years old - sports is most common
• 40-69 years old - machinery is most common
• >70 years old - falls are most common

ASSOCIATED CONDITIONS
• nail bed injuries, associated with distal phalanx fractures
 DEFORMING FORCE
PROXIMAL PHALANX
• apex volar angulation due to
• proximal fragment pulled into flexion by interossei
• distal fragment pulled into extension by central
slip

MIDDLE PHALANX
• apex volar angulation if distal to FDS insertion
• apex dorsal angulation if proximal to FDS insertion

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 PRESENTATION
History Motion

hand dominance, baseline function, • Assess for scissoring of digits 

occupation and hobbies, mechanism of • Indicates rotational component
injury  • Assess via tenodesis

Neurovascular
Physical Exam
• Digital nerve
• Inspection
• Two-point discrimination test 
• Swelling 
• Vascular assessment   
• Ecchymosis • Cap refill <2 sec
• Deformity (angular, rotation, shortening)
• Open wounds

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 Divergence of the small
Scissoring digit Malrotation finger while making a
fist

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 IMAGING

RADIOGRAPHS
Recommended Views:
• PA
• Lateral
• Oblique

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 TREATMENT
Depending on location of fracture:
• Proximal phalanx fractures
• Middle phalanx fractures
• Distal phalanx fractures

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 PROXIMAL AND MIDDLE PHALANX FRACTURES

Nonoperative Indications
• extraarticular fractures with < 10° angulation or < 2mm shortening and no rotational
deformity
• non-displaced intraarticular fractures 

Operative Indications
• extraarticular fractures with > 10° angulation or > 2mm shortening or rotational
deformity
• displaced intraarticular fractures
• unstable or irreducible fracture pattern 
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 DISTAL PHALANX FRACTURES

Nonoperative Indications
• most cases

Operative Indications
• distal phalanx fractures with nailbed injury

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 BUDDY TAPING SPLINTING

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 Summary
• Phalanx Fractures are common hand injuries that involve the
proximal, middle or distal phalanx.
• Diagnosis can be confirmed with orthogonal radiographs of the
involve digit.
• Treatment involves immobilization or surgical fixation
depending on location, severity and alignment of injury.

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 THANK YOU

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